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Presentation Mdc Pulmo

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UPPER- LOWER RESPIRATORY PATHOLOGIES

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SINUSITIS Sinusitis is the inflammation/infection of the mucosa of 1 or more paranasal sinuses. Definitions: Acute Bacterial Sinusitis : Bacterial infection of the paranasal sinuses lasting less than 30 days in which symptoms resolve completely. Subacute Bacterial Sinusitis : Bacterial infection of the paranasal sinuses lasting between 30 and 90 days in which symptoms resolve completely. Chronic Sinusitis : Episodes of inflammation of the paranasal sinuses lasting more than 90 days. Patients have persistent residual respiratory symptoms: cough, rhinorrhea, nasal obstruction.

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ANATOMY / DEVELOPMENT 4 Sinuses: Maxillary, Ethmoidal, Frontal, Sphenoidal MAXILLARY SINUSES DEVELOPS DURING 3rd & 4th GESTATIONAL MONTH WITH PNEUMATIZATION BETWEEN BIRTH AND 12 MONTHS OF AGE ETHMOID SINUSES DEVELOPS DURING 3 rd & 4 th GESTATIONAL MONTH. IS PRESENT AT BIRTH, DEVELOPING UNTIL 12-14 YEARS OF AGE SPHENOID SINUS DEVELOPED BY AGE 8-10 YEARS FRONTAL SINUS DEVELOPS DURING 5 th AND 6 th YEAR.

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In the sides of the nasal septum, there is 3 shelf-like structures where discharge is drain and is called Turbinates MAXILLARY ANT. ETHMOID MIDDLE MEATUS FRONTAL POST. ETHMOID SUPERIOR MEATUS SPHENOID LACRIMAL DUCTS INFERIOR MEATUS (Largest and most visible)

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S/S: URI symptoms for > than 10 days (acute) or > than 12 weeks (chronic) *Low grade fever (50%) *Mucopurulent rhinorrhea in middle meatus or postnasal discharge. (95%) *Nasal mucosa congested/edematous *Cough present during daytime but is worse at night (90%) *Painless periorbital edema occurring in the morning and with bad breath. *Facial pain/pressure above or below the eyes, and Headache. It may change with position, increasing when leaning forward or during percussion. (70%) *Frontal, Maxillary, and Ethmoid area are tender to palpation/percussion *Periorbital swelling is suggestive of ethmoid sinusitis

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Timpanostomy Tubes: Insertion of ventilation tubes in the TM for ventilation/drainage. (Silicone) most recent development Incision on Anterior Inferior region. Not responding to ATB treatment Recurrent AOM infections in a period of time *Uni or bilateral chronic OME for more than 3 months. *Conductive hearing loss in excess of 30 dB in patients with Otitis media with Effusion *Recurrent AOM infections: Children with > 3 separate episodes within 3 months Children with 4 episodes in a 6 months period or with 6 episodes in a 12 months period

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AOM WITH OTORRHEA THROUGH TYMPANOSTOMY Insertion of ventilation tubes in the TM for ventilation/drainage. Otorrhea is a major complication after their insertion Bacterial isolated: S.pneumonia, H. influenza, M. catarrhalis, S.aureus, P. aeruginosa. S/S: Fever, draining from ear, earache. Tx: Due to the inflammatory response from these bacterias, it is better to combine an Atb with dexamethasone 0.1% topical. (Ciprodex Otic for patients above 6 months, Floxin) If it is necessary, can give oral Atb.

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Cholesteatoma. It is an accumulation of desquamated epithelium or keratin that often appears as a white mass behind or involving the tympanic membrane; it may be congenital or acquired. The acquired type is commonly caused by recurrent acute or chronic otitis media, but can also be iatrogenic (after tympanostomy tube placement or other procedures). Cholesteatoma can enlarge and erode the bone, including the ossicles, causing hearing loss. They can also become infected, leading to a foul-smelling discharge from the ear. A cholesteatoma needs to be removed surgically.

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ALLERGIC RHINITIS Def. of Rhinitis: Is an inflammation of the nasal mucous membranes. However, with allergic rhinitis, other organs or tissues are involved, such as eyes, ears, sinuses, oropharinx. -Is an Immunologic Hypersensitivity Disorder Type I -Is often a predisposing factor or exacerbation of asthma, rhinosinusitis, nasal polyps. -Characterized by one or more nasal Sx- sneezing, itching, congestion, rhinorrhea. -Diagnosis is based on Hx, physical findings, and Lab.

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Impact of Allergic Rhinitis Most common form of atopic disease Affects 40 million Americans Prevalence estimates: 10/30% of adults, 40% of children Peak incidence in childhood and adolescence Almost 70% of the patients have nasal congestion Nearly 17 million office visits a year Direct costs per year of about 6 billion dollars Increase absenteeism and reduced productivity 75/80% of patients with asthma have allergic rhinitis. Genetics: High incidence in families with atopic disease (eczema, asthma)

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There are 2 phases of allergic response: Early phase response to antigen: < 5- 30 minutes after allergen exposure. -Allergen comes in contact with IgE-primed mast cells and basophils -Caused by the immediate release of histamine and other mediators (leukotrienes). -Causing bronchoconstriction, edema, and stimulation of mucous gland that leads to: Production of secretions: Increase in vascular permeability leads to plasma exsudation Vasodilation leads to nasal congestion and sinus pressure Late phase response to antigen: 2-12 hours after allergen exposure Characterized by sx beginning 4-8 hours after allergic exposure. This phase occurs because of inflammation resulting from the recruitment of inflammatory cells (Cytotoxic proteins released by neutrophils, eosinophils, macrophages, lymphocytes – damaging the Epithelial cells) to the mucous membranes. This phase has more congestion, rhinorrhea and less sneeze/itching.

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INFECTIOUS RHINITIS Most common cause of nasal symptoms in children is viral URI. Specially in day care/kindergarten/winter months Last between 7-14 days, symptoms resolving around the 7th/8th day Fever may or may not appear Clear mucus discharge, changing to green/yellow after a few days, Cough  post nasal drip Turbinates can be swollen and erythematous. Secretions are watery or thick, clear or colored. Complicated by sinusitis or obstruction by adenoidal hypertrophy TX: ATB (purulent mucus), mucolitics, cough syrup

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EPISTAXIS Is bleeding from the nose, being evident anteriorly through the nares or posteriorly through the nasopharynx. Etiology: vide slides Pathophysiology: Nasal mucosa blood supply originates from internal/external carotid Blood vessels of nasal septum and lateral walls have little protection, and the thin mucosa is prone to drying. Most important vascular plexiform network is the: Kiesselbach’s plexus in the anterior nasal septum. Woodruff’s plexus in the posterior part of nasal septum Epidemiology: Children 2-10 years are most commonly affected Nosebleed are more common in winter.

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FOREIGN BODY ASPIRATION Children often ingest or aspirate a foreign body, with variable outcomes. Missed or late diagnosis may lead to serious morbidity or death. Children will put almost anything they find into their mouth; like food (peanuts, grapes, candy, hot dog), batteries, buttons, coins, crayons, jewelry, marbles, paper clips, pen caps, pins, screws, toy parts, chicken or fish bones. History: Most ingestions and aspirations of a foreign body occur in a normal child in their home, under their parents care. Poor safety proofing; unattended child, running with food, or handling a small object It’s a toddler with a sudden onset of cough, choking, persistent wheezing, gags, and vomits at the time of ingestion Peak age: 6 months-4 years Pathology: Usually foreign object lodge below the carina. In toddlers, lodge in either mainstem In older children, they lodge in the Right mainstem

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On the left, an endoscopic view of the throat shows almost complete blockage of the airway (arrow). This finding is typical of epiglottitis. On the right, the airway has been opened (arrow) after insertion and removal of an endotracheal tube, although some redness and blood remain

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ASTHMA Is a chronic inflammatory disorder affecting large and small airways Is a Reversible airways Ds, characterized by: Airway inflammation Secretion of mucus Bronchoconstriction Hyperresponsiveness to various stimuli Epidemiology: Most common chronic illness in children 12-15% of school age children 80-90% of children will have first symptom by age 3 60-70% will be free of symptoms by adulthood Etiology: Extrinsic- caused by several allergens, family history always positive Intrinsic- caused by: cold, infection, exercise, emotional,